A Conversation About Women’s Health

Monday, November 5, 2018

Experts at Rush offer advice for medical problems and maintaining health

Women’s bodies are more complex than men’s, and their health issues and needs are more complex as well. At a recent event hosted by Rush University Medical Center, a panel of women physicians at Rush discussed a range of subjects, including universal health concerns (blood pressure, stress management) and specific women’s health issues (hormone therapy, pelvic floor problems). An edited transcript of that discussion appears below.

The moderator of the discussion was Sheila Dugan, MD, a professor in the Department of Physical Medicine and Rehabilitation and co-director of the Rush Program for Abdominal and Pelvic Health. The panelists included Martha Clare Morris, ScD, professor in the Department of Internal Medicine and director of the Rush Institute for Healthy Aging; Patricia Normand, MD, an assistant professor in the Department of Psychiatry, who leads the Mindfulness Based Stress Reduction Program at Rush; Tochi Okwuosa, DO, an associate professor in the Department of Internal Medicine and director of cardio-oncology services at Rush; and Barbara Soltes, MD, an associate professor in the Department of Obstetrics and Gynecology and the medical director of the Rush Midlife Center for Women.

Sheila Dugan: It’s great to see a room full of women. It makes me miss my sisters and think about my mother.

My specialty is called physical medicine and rehabilitation. I am a non-operative physician, and I work closely in the area of orthopedic pain. I deal with a lot of spine care and joint problems.

I would like each of our panelists give one pearl of wisdom for each of us. My pearl is, if you’re looking for the magic pill, it’s movement. It’s physical activity.

Women that move have less heart disease, less cancer, less depression. They also have less physical disabilities. So if you want to keep doing what you want to do, you’ve got to move, and you’ve got to find something you like to do and do it.

Our next speaker is Patty Normand.

Patricia Normand: About 20 years ago or so, through my own experiences, I became interested in mindfulness and meditation. Mindfulness is simply being present in the moment. I was thrilled to discover that there was a way to teach it to people through a program called mindfulness-based stress reduction. When I came to Rush, we started that program. It’s an ongoing eight-week program.

One pearl: We live in a very, very stressful world. The only thing we can change is ourselves. We cannot change, usually, the things around us or the people around us. So you have to actively work at managing stress.

One of the main ways is working with things that give you a sense of urgency, and try to figure out if something is as urgent as it seems. Most things in life are not an emergency. But when we’re feeling stress, it feels like an emergency.

One very simple that you can do to decrease stress is to turn off the news. Stop listening to the news.

Also, stop trying to multitask. Our world, you know, with our little gadgets, everybody wants to multitask. But your brain really can’t be in two places at once. Then there’s mindfulness, which gives you a way of pausing from whatever stress is going on around you.

Last but not least, being kind to yourself can be a stress reducer, because oftentimes we’re very hard on ourselves. So practice some self-compassion.

Dugan: Tochi Okwuosa is our next presenter. She’s a cardiologist interested in your heart and what happens to your heart when you’ve been through breast cancer treatment.

Tochi Okwuosa: I was recruited to develop a cardio-oncology program at Rush. That is, care for heart disease in cancer patients, and heart disease that has to do with cancer and/or cancer treatment. It is important in patients, whether they have heart disease at baseline before they start treatment; people that that are currently in treatment and who end up developing heart disease as a result of treatment; and those that are cancer survivors who received treatment and now have cardiovascular consequences in subsequent months or years.

The important pearl I hope you will take away from all of this is to be in charge of your health. Know the treatments that you or your family members are going through. Know what the side effects are; and discuss them with your physician. Know what symptoms to watch out for, and how best to manage them.

Dugan: Next we have Martha Clare Morris, who is looking at what we’re eating and how it affects our thinking and our cognitive abilities.

Martha Clare Morris: When I came to Rush, we started up a very large community study on the South Side of Chicago called the Chicago Health and Aging Project, which followed  10,000 people over a 20-year period. We did extensive evaluations of these participants to assess their health and lifestyle and followed them over time to see who developed Alzheimer’s disease. We discovered a lot about the risk factors for Alzheimer’s disease and decline in cognitive abilities from this study.

At the time we started this study, there was very little research on nutrition as it relates to the aging brain. Over the next 20 to 25 years, we made discovery after discovery about the nutrients and foods that affect the brain and either cause it to age quicker, or protect it from aging. We found out so much about nutrition and the brain.

My pearl, from the diet perspective, is to eat a salad every day. Out of all the foods that we looked at, the most powerful in terms of slowing cognitive decline was leafy green vegetables. They include spinach, kale, collards, arugula – they’re jam packed with a whole array of nutrients that we found individually are important to the brain. With just that one meal of the day, you can load up on so many brain-healthy nutrients.

Dugan: Finally, we have Barbara Soltes, who had to run in here. Hi Barb, how are you? Welcome.

Soltes: I am a gynecologic endocrinologist at Rush, and a certified menopause practitioner. I am also the medical director of the Rush Midlife Center, which just opened in August of last year. It provides comprehensive, integrated, specialized health care just for women over age 40. We have currently ten specialists there that just focus on women’s health care. And we come together to implement a plan, a long term plan for women’s health and longevity of their life.

Dugan: We hope that we’ve stimulated some thoughts. Does anybody have a burning question?

Question: I’m sure a lot of us have trouble sleeping. I know I do. I’ve tried all of the remedies, and I usually stop within a short period of time because of headaches or it didn’t work or whatever. So I’m now to marijuana which I’m about to try it because it’s legal in Maryland, legal in Maine where I go sometimes. I’m wondering if you can speak to that.

Soltes: I can’t address the marijuana part of that. We do have two sleep specialists. We have a sleep physician and a sleep therapist in our center. They really promote sleep hygiene and really staying on a schedule and melatonin as well as using meditation apps.

In the beginning, sometimes we do try some of the sleep aids, but we find that there’s usually an underlying reason why people aren’t sleeping, and the first step would be to make sure you have a sleep study so that we know exactly what we’re dealing with. In the early years of menopause, which are the first five years from the last menstrual cycle, we know it’s a hormonal issue. Sometimes we can correct that just by adding hormones. But five, ten years after the last menstrual period, there’s usually some other underlying reason.

Question: My question is in relation to inflammation. Is it lack of hormones or is it the fact that we’ve been on this earth as long as we have? Should we be punishing ourselves by aching and not feeling well, or should we be taking some kind of hormone replacement?

Morris: There are changes with aging. You’re not going to avoid aging, but you can slow it down. Both diet and exercise play to the middle. Moderate exercise can be better than extreme exercise, which can be more harmful to the body. There’s going to be genetic factors and things that you can’t avoid or help, they’re out of your control, but you can certainly slow aging with healthy lifestyle practices.

Dugan: As a musculoskeletal physician, I know we certainly accumulate different rates of arthritis. As we get through the higher decades, we sort of have to modify our activity depending on which joint is hurting, but saying, ”I ache so I’m not going to do anything,” is not a great answer.

You should work on your flexibility and your relaxation with yoga. Probably you all need to have a good physical therapist on your speed dial, who knows your shoulder, who knows your back, who knows your knee.

You also need to get your heart rate up. Studies of moderate intensity exercise have found that when you’re a little bit short of breath, it has more benefits than a leisurely stroll. Take it to a lower impact and then work your way back up. And you know marathons may not be in our futures anymore and so we have to find other things that we can do to get our dose of exercise.

Normand: There’s a distinction between pain and suffering. Pain is a physical sensation. Suffering is everything you put on that physical sensation. As an example, if I sprain my ankle and end up in a cast, you know, it hurts. But if I then start thinking about, I have to drive the kids to school, I have to go get this, how am I going to run around the office? That’s the suffering part.

If you can just let go of the suffering part and be in the moment with what you need to do, then it lessens the pain. Because, you know, pain thresholds vary a lot, and your mind has a lot to do with that as well.

Soltes: I have to address the hormone issue because I’m a hormone doctor. The Women’s Health Initiative, the largest study that we had, was released back in 2001, and it really threw everybody in a whole tizzy about the whole hormone issue. We’ve now come full circle, and women are now taking hormones again because we have a different type of hormone. We’re using mostly bioidentical hormones.

If a woman is close to her last menstrual period and she’s having some menopausal-type symptoms, provided she has no contraindication, she can use the hormones safely for up to ten years, provided they’re balanced. If a woman stops taking the hormones and it’s been several years, it’s a very bad thing for her to restart hormones.

What we’ve learned is that the hormones are protective in terms of the heart and allowing better pumping ability of the heart and less plaque formation, but after she stops them, the aging process ensues. Then if she were to add hormones after that, it actually accelerates the heart disease.  

The hormone issue and breast cancer is another whole story. But heart disease is the number one killer in women over 50. We know that hormones do protect the heart against heart disease and actually improve long term, positive outcome for women.

Question: Let’s talk about the pelvic floor. What is it? I’ve had four kids, and all of a sudden, it’s kind of hard to hold it. What do I do?

Dugan: Certainly carrying and delivering children is one risk for your pelvic floor to have been through a lot. It’s a very powerful set of muscles that attach from your pubic bone in the front all the way back to your sacrum, and then from one hip to the other.

It’s kind of like a trampoline, it does a lot of work to hold things up, and it comes with these specialized openings that have sphincters. You have a rectal sphincter and a urethral sphincter for urine and feces, and you have the vagina.

Sexual trauma is another risk factor for pelvic floor problems. One way your body responds is by being very tight. It also can occur if you had cancer, like uterine or colon cancer, if you had hemorrhoids, if you have fissures.

Then pain can feed back to the spinal cord and send messages to other nerves that go to your bowel and your bladder. Usually if your pelvic muscles are in trouble, it’s not a one stop thing, it’s can cause sexual issues, urinary issues, bowel issues, maybe then issues with exercise. It’s pretty complicated, and you should see somebody that can consider your history and everything that brings you to the table.

Question: My doctor said you should go to a pelvic floor specialist to learn exercises.

Dugan: Yes. You could also see a physical therapist. The American Physical Therapy Association has a group of certified practitioners; they’re called pelvic floor physical therapists. A pelvic floor physical therapist is another resource for you, because there are more of them than there are of me.

Question: We now know that the high points for hypertension have been lowered. So instead of 140/90, it’s now 130/80. I’m interested in what you all are doing.

Okwuosa: In our cardiology clinic, yes, that’s one of the things that we focus on. One of the things that the guideline is emphasizing is the fact that we should encourage patients to obtain blood pressure machines, and log their blood pressures at home; and then bring the log to their physicians for review.

This is important in two ways. Everybody knows about white coat hypertension, right? Sometimes when you come to clinic, your blood pressure is elevated, but then you go home and we see your blood pressures are completely fine. So if I decide to start you on a blood pressure medicine when you are in clinic and your blood pressure is high, then I would be doing you a disservice because your blood pressures are going to be too low at home.

When you come in and you sit down and you relax for a little bit before the doctor walks in, if somebody checks your blood pressure, it is usually lower than when you first came into clinic. It’s okay later on – when the doctor walks into the room – to request a blood pressure recheck.  

This works the other way around too. We are discovering a new phenomenon where some people may have they have a lot of stress at home, and blood pressures are high at home where they live. They come to the doctor’s office and their blood pressure is a little bit better because they get away from the stressors at home.

So buying a machine, and keeping a blood pressure log is very important; and bring it with you to clinic. We should not make decisions on blood pressures based on clinic values anymore. We have to use your overall whole numbers. 

Question: We’ve talked a lot about physical movement and diet and such. What about mental sports so to speak, exercising your brain in order to keep your brain going? There are lots of different puzzles and apps and things like that. Are there any studies that show that those are worthwhile?

Morris: Quite a few trials have shown benefit of cognitive training. The prevailing theory is is that the more you challenge your mind, the more synaptic connections that you create, that protects you from many kinds of pathologies that develop in the brain. It’s called the theory of cognitive reserve.

In some of our Rush studies, the people in the study are free of dementia when they enroll, and they’ve agreed to donate their brains to research when they die. We measure their cognitive abilities during the years before their death, and then when they die, we examine their brains for different pathologies. We found that about a third of people who have so much Alzheimer’s disease pathology in their brain that they have a post-mortem diagnosis of Alzheimer’s disease never showed symptoms during their lifetime. A third.

According to the theory of cognitive reserve, individuals who challenge their minds develop many synaptic connections in their brains, so that the neuro-circuitry can go around the pathology that has accumulated in the brain. Doing things like learning a new language or a new instrument – not doing like the same old thing every day, but really challenging yourself all the way through life – keeps building that neuro-circuitry. 

Normand: Also, in terms of mindfulness, meditation, there are age-related changes to the brain, our brain shrinks and such, but that some of those were offset by practicing meditation. It may be that meditation is like doing a crossword puzzle or Sodoku or learning a language, something that activates different parts of your brain.

Normand: Also, in terms of mindfulness, meditation, there are age-related changes to the brain, our brain shrinks and such, but that some of those were offset by practicing meditation. It may be that meditation is like doing a crossword puzzle or Sodoku or learning a language, something that activates different parts of your brain.

Dugan: It’s been such a great conversation. Obviously people here are thinking about their health, they’re thinking about the health of their children, they’re thinking about the health of their communities. That’s what we think about as clinical people and scientists. Thanks so much for your attention, your engagement.